MEDICARE: PALMETTO LONG-TERM CARE COALITION

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	207R00000X	Internal Medicine Physician
2	363A00000X	Physician Assistant
3	363LA2200X	Adult Health Nurse Practitioner
4	363L00000X	Nurse Practitioner

General Provider Information

NPI Number	:	1780073924
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PALMETTO LONG-TERM CARE COALITION

Provider Business Mailing Address
First Line	:	10900 NUCKOLS RD
Second Line	:	SUITE 110
City	:	GLEN ALLEN
State	:	VA
Zip	:	23060-9276
Country	:	US
Telephone Number	:	404-822-5378
Fax Number	:

Provider Business Practice Location Address
First Line	:	10900 NUCKOLS RD
Second Line	:	SUITE 110
City	:	GLEN ALLEN
State	:	VA
Zip	:	23060-9276
Country	:	US
Telephone Number	:	404-822-5378
Fax Number	:

Authorized Official
Title or Position	:	CHIEF OPERATING OFFICER
Name	:	KENNETH BRATTON
Credential	:
Telephone Number	:	404-822-5378

Provider Enumeration Date	:	01/12/2015
Last Update Date	:	01/12/2015

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